Healthcare Provider Details

I. General information

NPI: 1104896885
Provider Name (Legal Business Name): ELAINE LENORE ENSIGN PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/25/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 BRADFORD WAY
KINGSTON TN
37763
US

IV. Provider business mailing address

1002 BRADFORD WAY
KINGSTON TN
37763
US

V. Phone/Fax

Practice location:
  • Phone: 865-376-1585
  • Fax: 865-376-1587
Mailing address:
  • Phone: 865-376-1585
  • Fax: 865-376-1587

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License NumberP1360
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: